NATIONAL ASSOCIATION OF SOCIAL WORKERS. Standards for. Social Work Practice. in Health Care Settings

NATIONAL ASSOCIATION OF SOCIAL WORKERS NASW Standards for Social Work Practice in Health Care Settings 2005

NASW Standards for Social Work Practice in Health Care Settings

National Association of Social Workers Elvira Craig de Silva, DSW, ACSW NASW President (2005-2008) Elizabeth J. Clark, PhD, ACSW, MPH Executive Director Health Standards Working Group Nancy Campbell, MSW, LISW Nancy F. Cincotta, MSW Lisa E. Cox, PhD, LCSW, MSW Stuart Kaufer, ACSW, LMSW Carol P. Marcusen, MSW, LCSW, BCD Shirley Otis-Green, MSW, ACSW, LCSW NASW Staff Nancy Bateman, LCSW-C Evelyn P. Tomaszewski, ACSW Karyn Walsh, ACSW, LCSW 2005 National Association of Social Workers. All Rights Reserved.

Contents 5 Introduction 6 Background 8 Social Work Guiding Principles 9 Definitions 14 Standards for Professional Practice 14 Standard 1. Ethics and Values 15 Standard 2. Health Disparities 17 Standard 3. Cultural Competence 18 Standard 4. Confidentiality 19 Standard 5. Knowledge 20 Standard 6. Assessment 21 Standard 7. Intervention and Treatment Planning 22 Standard 8. Case Management 24 Standard 9. Empowerment and Advocacy 24 Standard 10. Client and Community Education 25 Standard 11. Teamwork and Collaboration 26 Standard 12. Workload 27 Standard 13. Documentation 28 Standard 14. Research 29 Standard 15. Performance Improvement 30 Standard 16. Access to Information and Technology 31 Standards for Professional Development, Education and Leadership 31 Standard 17. Qualifications 31 Standard18. Continuing Education 32 Standard 19. Supervision 33 Standard 20. Leadership 34 References 36 Acknowledgements

Introduction The constant growth, demands, and changes in health care have had a serious impact on the viability and need for social workers in all areas and settings of health care. More than 15 percent of the population or 45 million people in the United States were without health insurance coverage during 2003 (U.S. Census Bureau, 2004). Access to timely, comprehensive, and equitable health care for individuals in the United States varies considerably, with significant percentages of many populations having only limited access to health care. The growth in medical technology has offered hope and improved quality of life to many people; yet, the advances in technology have also raised health care costs and introduced social, legal, and ethical dilemmas for individuals, families, and health care providers. These psychosocial implications of health care are what social workers are trained to address. Currently, health care social workers provide services across the continuum of care and in various settings. Social workers are present in public health, acute, and chronic care settings providing a range of services including health education, crisis intervention, supportive counseling, and case management. In response to critical incidents that are both global and national, health care social workers are increasingly trained to provide interventions to prepare for and respond to traumatic events and disasters. The health care system in the United States is complex and multidisciplinary in nature, and 5

may include a network of services such as diagnosis, treatment, rehabilitation, health maintenance, and prevention provided to individuals of all ages and with a range of needs. Multiple sources of financing, ranging from Medicare and Medicaid to private insurance, provide further challenges. Many consumers lack health insurance or have inadequate coverage, which causes financial stress on consumers and providers. Professional social workers are well equipped to practice in the health care field, because of their broad perspective on the range of physical, emotional, and environmental factors that have an effect on the well-being of individuals and communities. These standards are developed to meet the needs of social workers in multiple health care practice settings and to help the public understand the role of the professional social worker. The National Association of Social Workers (NASW) recognizes that standards alone cannot improve the quality of practice unless they are disseminated and implemented at the practice level. Client satisfaction and improved quality of care result when social workers and administrators recognize and use these standards. Background Social workers have been involved in the health care field since the turn of the 20th century. The profession s earliest concerns were with making health care services available to the poor and with improving social conditions that bred infectious diseases such as 6

tuberculosis. As the social work role expanded, social workers joined other health professions in the delivery of high quality services. Today, social workers can be found in every component of the health care system. In 1977, NASW published Standards for Hospital Social Services. In 1980, the Standards for Social Work in Health Care Settings were developed and replaced the hospital standards. Between 1981 and 1982, the NASW Board of Directors approved the new standards, and three subsections were developed, approved, and added to the health care standards. The subsections included the Standards for Social Work in Developmental Disabilities, Standards for Social Work in End-Stage Renal Disease Treatment Settings, and Standards for Social Work in Public Health Settings. In the early 1980s, a capitated system for payment of Medicare services in acute health care settings, known as diagnostic-related groups (DRGs), was initiated by the federal government. This initiative, generically known as managed care, fundamentally altered health care financing for both public and private health care systems. Managed care focused on reducing the length of stays in acute care facilities, and this led to a fundamental shift in the role of social workers in acute health care. Social workers became more focused on planning for an individual s transition to home or to another level of care. Social work services disappeared entirely from some health care settings due, in part, to a lack of data demonstrating the efficacy of social work services and loss of funding for those services. Yet, in other settings, social workers have prospered, gaining recognition through the 7

provision of specialized services in multiple health care arenas such as palliative care, ethics, ambulatory care, rehabilitation, and geriatric services. The NASW Standards of Social Work Practice in Health Care Settings are based on the consensus of expert health care social workers from across the country and are designed to enhance social workers knowledge, skills, values, and methods necessary to work effectively with individuals, families (broadly defined), health care providers, and the community when practicing in health care settings. Social Work Guiding Principles The basic values of social work, from promoting an individual s right to selfdetermination to having an attitude of empathy for the individual, are the foundation of social work practice. When confronting dilemmas or needs in health care, social workers can use the principle of client selfdetermination in matters where clients or their proxies are faced with such issues (NASW, 2004). Social workers have skills in cultural awareness and cultural competence, in which social work practice respectfully responds to, and affirms, the worth and dignity of people of all cultures, languages, classes, ethnic backgrounds, abilities, religions, sexual orientation, and other diverse features found in individuals (NASW, 2001). Social workers look at the person-in-environment, including all of the 8

factors that influence the total health care experience. Social workers practice at the macro and micro level of health care and thus have the ability to influence policy change and development at local, state, and federal levels and within systems of care. Social work research in health care benefits not only individuals and families, but also the very existence, effectiveness, and validation of the profession. These standards offer a guide for social workers practicing in any health care setting. Definitions Bioethics Bioethics is the analysis and study of moral, legal, social, and ethical considerations involving the biological and medical sciences. Many health care settings have organized forums such as bioethics committees, institutional review boards, or consultation processes to address ethical dilemmas and questions. Biopsychosocial spiritual Perspective The biopsychosocial spiritual perspective recognizes that health care services must take into account the physical or medical aspects of ourselves (bio); the emotional or psychological aspects (psycho); the sociocultural, sociopolitical, and socioeconomic issues in our lives (social); and how people find meaning in their lives (spiritual). This approach draws from the strengths perspective of social work practice. The strengths perspective recognizes an individual s strengths and abilities to cope 9

with problems; and awareness and use of the client s strengths is part of the foundation of social work theory and practice. The strengths perspective is seen in social work practice through our role of enhancing personal strengths and resources, helping clients solve both interpersonal and environmental problems, and helping clients mobilize for change. The strengths perspective helps clients use their past successful choices and behaviors, skills, and insights to resolve or work through a current crisis (Tomaszewski, E. P., 2004; Saleebey, 2003). Case Management Case management, sometimes used interchangeably with care management, is the collaborative process of assessment, planning, and facilitation for options and services to meet an individual s complex needs. When appropriate, this would include arranging, coordinating, monitoring, evaluating, and advocating on behalf of the client and/or his or her family for the multiple services needed from a variety of social service and health care agencies. Case management addresses both the individual client s biopsychosocial-spiritual status (micro level) as well as the state of the social systems in which the services operate (macro level). Client/Patient/Consumer These terms refer to the person receiving care and treatment from physicians and allied health care personnel. Social workers generally use the term client to identify the individual, group, family, or community who seeks or is provided with professional services. The client is often seen as both the individual and the 10

client system or those in the client s environment. The term consumer is also used in settings that view the client as the consumer, that is, one capable of deciding what is best for her or himself and encourages self-advocacy and self-judgment in negotiating the social service and welfare system. The term patient is more commonly used by social workers employed in health care settings (Barker, 2003). Continuum of Care The care continuum includes the specialized health, social work services, rehabilitative, and home-based services that a seriously or chronically ill or injured person might need. This continuum addresses both the medical care and the other services that promote the patients well-being (Barker, 2003). Continuity of Care Continuity of care ensures the coordination of care within an organization or across different agencies or settings to reduce duplicate services, to address gaps in existing services, and to ensure consistent and continuous services for the client as they transition in care or are discharged. Disabling Condition A disabling condition is considered a temporary or permanent reduction in a client s capacity or functioning based on the inability to perform some activities that most others can perform. A disabling condition can be congenital, can be the result of an accident or trauma, or more frequently is the result of chronic illness (that is, diabetes, hypertension). 11

Health Care Settings Health care settings are practice areas in which assessment, care, and treatment address the physical, mental, emotional, and social well-being of the person; and address prevention, detection, and treatment of physical and mental disorders with the goal of enhancing the person s biopsychosocial and spiritual well-being. The health care setting includes personnel who provide the necessary services (for example, physicians, social workers, nurses, hospital attendants); appropriate service delivery facilities (for example, hospitals, hospice, assisted living, medical centers, and outpatient clinics); and educational and environmental facilities that work to help prevent disease (Barker, 2003). Health Planning Health planning is conducted in government organizations, medical and research organizations, and educational institutions and in prevention, early intervention, treatment, and follow-up. Planning should involve determining and ensuring the number of necessary health care personnel presently and in the future, and how to both finance and control costs. It includes where to locate facilities, how to provide the most effective means of service delivery, and how to provide services in a cost effective manner (Barker, 2003; NASW, 1987). Managed Care Managed care is a process designed to manage health care costs primarily through the private sector, although Medicaid s or Medicare s capitated systems are a form of managed care. It is a technique used by insurance carriers 12

and characterized by preauthorization to qualify the patient for particular services; preauthorization for a given amount of care; review of treatment and patient response(s); utilization review; predischarge planning to ensure the patient is ready to be released (having received the care required) and has an aftercare plan. Managed care plans include preferred provider organizations (PPOs), health maintenance organizations (HMOs), or a combined version through a point-ofservice (POS) plan. Medicaid Medicaid is a government-funded health insurance program that provides payment for hospital, nursing home, home care, dental, and medical services to people who meet disability guidelines and income eligibility requirements. The Medicaid program is a shared federal/ state/county program and although there are certain federal standards, states have a choice of benefits which they can choose to cover or not. Medicaid, administered by the Centers for Medicare and Medicaid Services (CMS), is the largest source of funding for medical and health-related services for people with a limited income (Centers for Medicare and Medicaid Services, 2004b). Medicare Medicare is a national health care program, administered by CMS, for most people age 65 and older, people with a variety of disabilities who are under age 65, and people with end-stage renal disease (ESRD), which is permanent kidney failure requiring dialysis or a kidney transplant (CMS, 2004a). Medicare is funded through a combination of 13

employer employee contributions (as part of the person s Social Security), from earmarked taxes, and general federal revenues. Since Medicare is a federal program, benefits are the same in all 50 states. Public Health Model The Public Health Model of services focuses on the health of the individual, the family, and the larger community or general public and is administered by federal, state, and local agencies. The goal of programs, policies, and health care personnel is to prevent and treat disease, identify and eliminate environmental hazards, prolong life, and promote better health (Barker, 2003; NASW, 1987). Standards for Social Work Practice in Health Care Settings Standard 1. Ethics and Values Social workers shall have knowledge of and practice according to the guidelines established by the NASW Code of Ethics (NASW, 1999). Interpretation The primary mission of the social work profession is to enhance human well-being and help meet the basic human needs of all people, with particular attention to the needs of people who are vulnerable, disenfranchised, oppressed, and living in poverty. The mission is rooted in a set of core values. These core values, embraced by social workers throughout the profession s history, are the foundation of social work s unique purpose and perspective: 14

service social justice dignity and worth of the person importance of human relationships integrity competence In a health care system increasingly driven by technological advances, the ethical and moral questions and dilemmas raised for clients, families, and health care professionals are numerous and complex. Health care settings have designed a number of different systems to ensure ethical behavior among health care practitioners. Ethics committees are often used to provide objective reviews to health care providers and clients and families, when there is conflict between providers or providers, clients, and families. Institutional review boards are used to protect clients from the potential of experimentation in research projects. Social work supervision and peer consultation can also be used to discuss ethical issues facing practitioners. Standard 2. Health Disparities Social workers practicing in local, state, national, and international health care settings require knowledge and skills to help them recognize and address inequalities and injustices directed toward clients, organizations, and communities related to access to care and provision of health services. Interpretation Many social workers have historically delivered services as part of community-based organizations and public health programs to address health disparities among those who 15

are least likely to be able to gain access to adequate care. Social workers have an ethical obligation to address the health care needs of these groups and advocate for change to ensure access to care. Training of health care professionals to achieve a level of cultural competence an understanding of practice patterns and attributes of diverse groups is an essential part of basic and continuing education for all health care professionals, including social workers (Gilbert, 2003). Health is a matter of both economics and social well-being. Both domestically and internationally, health care social workers strive to gain knowledge about health care: behavior, expenditures, reforms, systems, teams, insurance, health maintenance organizations, health protective behaviors, and more. Social workers also help clients to gain access to health care as they navigate between and among complex service delivery systems and entitlements. Different entities shape public and global policies in every country. Therefore, social workers must keep abreast of policies to competently help clients and to assess physical, environmental, historical, situational, cultural, and structural factors that affect health care systems. Accessibility to preventive, palliative, and curative health care depends largely on the client s ability to pay, and often, people cannot afford existing fees. In many nonprofit community-based clinics, services are provided on a first come-first serve basis (often with a long wait or long lines) and are limited by 16

a shortage of supplies and equipment. Increasingly, private systems of care emerge alongside public systems and other health care providers to care for the uninsured or underinsured who need health services, yet prefer to care for those who can pay fee-forservices. When these realities exist, social workers shall act as brokers, advocates, and mediators for clients. Standard 3. Cultural Competence Social workers shall develop and maintain an understanding of the history, traditions, values, and family systems of client groups as they relate to health care and decision-making. In compliance with the NASW Standards for Cultural Competence in Social Work Practice (NASW, 2001), social workers shall have a sensitivity to and awareness of the diversity in cultural groups and integrate this knowledge into their practice. Interpretation The importance of recognizing, respecting, and understanding other cultures and related health beliefs lays a foundation to build therapeutic alliances with clients and families. Social workers are responsible for selfreflection regarding the impact of their own cultural beliefs on their professional and personal life. Social workers in health care shall approach each client and family interaction from a perspective of cultural respect and awareness. This implies reluctance to stereotype individuals based on assumed group similarities and seeks instead to ask individuals what aspects of their cultural experience are 17

meaningful in understanding a particular health care need. Social workers recognize that ethnic, cultural, spiritual, and religious factors can have an impact on health care choices and adherence to regimens of care. Appreciation of cultural influences is especially important for clients at critical health junctures, such as birth, diagnosis of a major illness, and facing the end of life. Social workers have a responsibility to assist the client and family system in observing culturally meaningful practices whenever possible. When delivering culturally competent services, social workers should be guided by the NASW Standards for Cultural Competence in Social Work Practice (NASW, 2001). Standard 4. Confidentiality Health care social workers shall maintain appropriate safeguards for the privacy and confidentiality of client information. Interpretation Social workers must be familiar and comply with local, state, and federal mandates related to confidentiality. Professional judgment in the use of confidential information shall be based on best practice, ethical, and legal considerations (including the federal Health Insurance Portability and Accountability Act [HIPPA] regulations). Clients, families, and other professionals should be informed of the confidentiality limitations and requirements before services are initiated and in all phases of the health care experience. 18

Standard 5. Knowledge Social workers in health care settings shall demonstrate a working knowledge of current theory and practice and integrate such information into practice. Interpretation The social worker uses knowledge about, and psychosocial implications of, illness, injury, and health conditions to provide social work services to clients and families to help them manage and cope with the impact of such health matters. Social workers have expertise in communication; navigating systems of care, resources, client and family coping skills; and the comprehensive impact of health conditions on the client. With the person-in-environment perspective, social workers look at all of the influences and aspects of a person s life to complete a thorough assessment and treatment plan with the client, family, and other health care professionals. Essential areas of knowledge and understanding about health care include: the roles and functions of social work in health care the biopsychosocial needs of clients and families the physiological elements of illness and their impact on psychosocial functioning the psychological and spiritual needs of clients and families and how to ensure that they can be addressed community resources to assist clients and families the disparities across cultures and economic groups in gaining access to and funding for health care 19

ethical and legal questions and dilemmas laws, regulations, and policies affecting clients, families, and social work practice the accreditation and regulatory standards governing settings providing health care evidence-based practices and social work research in health care the needs of special populations. Standard 6. Assessment Social workers shall provide ongoing assessment, including gathering comprehensive information to use in developing interventions and treatment strategies. Interpretation Assessment is a fundamental process of social work practice. Treatment and intervention strategies/plans require that social workers both assess and reassess client needs and modify plans accordingly. Social work assessments in health care settings include considering relevant biomedical, psychosocial, and spiritual factors and the needs of the individual client and the family (as defined by the client) (NASW, 2004). A comprehensive, culturally competent assessment includes: past and current health status including genetic history of family health the impact of health conditions or treatments on cognitive, emotional, social, sexual, psychological, or physical functioning the impact on body image, intimacy, and sexuality 20

social history, including current living arrangement and household environment work, school, or vocational history stage in the life cycle and related and relevant developmental issues cultural values and beliefs, including views on illness, disability, and death family structure and the client s role within the family social supports, including formal and informal support systems behavioral and mental health status and current level of functioning, including history, suicide risk, and coping styles financial resources, including access to and type of health insurance. Comprehensive assessments shall address unique needs relevant to special populations, including children, people with severe and persistent mental illness, immigrants and refugees, people with substance use disorders, victims of violence or trauma, homeless people, and people with physical or psychiatric disabilities. Standard 7. Intervention and Treatment Planning Social workers implement intervention and treatment plans that promote client well-being and ensure a continuum of care. Planning shall be based on a comprehensive, culturally competent assessment with interdisciplinary input. Interpretation Intervention and treatment plans are steps identified by the health social worker, in collaboration with the client and with other 21

members of the team, to achieve objectives identified during assessment. Social workers shall be able to adapt practice techniques to best meet client needs within their health care setting to work effectively with individuals across the life-span, with different ethnicities, cultures, religions, socioeconomic and educational backgrounds, and across the range of mental health and disability conditions (NASW, 2004). Intervention or treatment plans may include: strategies to address needs identified in the assessment information, referral, and education individual, family, or group counseling vocational, educational, and supportive counseling psychoeducational support groups financial counseling case management discharge planning interdisciplinary care planning and collaboration client and systems advocacy goals and objectives. Standard 8. Case Management Social work case management shall optimize client functioning. Case management facilitates collaboration among providers to address the client s biomedical and psychosocial needs to better provide efficient, appropriate, and beneficial health care services to a client with (often) multiple needs. 22

Interpretation Social work case management requires the professional social worker to develop and maintain a therapeutic relationship with the client, which includes linking the client with resources that provide a range of services, resources, and opportunities to enhance successful quality outcomes for the client. Culturally competent case management is both micro and macro in nature and requires interdisciplinary care planning and collaboration with other professionals to maintain a team-oriented approach. Case management may include having regular meetings with the client and family and assisting the client to navigate systems. The scope of services would include the following: psychosocial assessment, including diagnoses, interventions, and treatment plans financial assessment, planning, and intervention case facilitation patient and family counseling crisis intervention quality improvement resource brokering/referral/development continuity of care planning system integration outcome/practice evaluation teamwork/collaboration patient/family education patient/family advocacy 23

Standard 9. Empowerment and Advocacy Social workers have a responsibility to advocate for the needs and interests of clients and client systems in health care, including advocating for larger system change to improve access to care and improved delivery of services. Interpretation Social workers have a special responsibility to advocate for the needs of the disenfranchised or the most vulnerable of the population at both the micro and macro levels. Social workers will identify barriers to services and actively seek to resolve them. The responsibility to advocate for quality improvement also implies a responsibility for health social workers to act as advocates to expand the role of the profession, develop leadership programs, and mentor new professionals. Standard 10. Client and Community Education Social workers act as educators for clients, families, the community, and other professionals regarding disease prevention, impact of illness and disease progression, advocacy for benefits, health maintenance, and adherence to treatment regimens. Interpretation Social workers have a formal role as educators. Social workers gain knowledge and expertise in the health practice setting from other professionals and from formal education, work, or teaching experience. They have the knowledge and skill to implement the principles of learning theories in education programs, activities, and resources. They 24

communicate and collaborate with departments and other staff to foster client education. They serve with other members of the health care team for program and resource development, planning, implementation, and evaluation. Social workers use a variety of methods to define and identify learning needs of individuals and families. Assessment identifies the educational needs based on the expressed needs of individuals, family members, and significant others. The social worker identifies deficiencies in the knowledge base of the client and works with the client to obtain the needed information and resources. Social workers collaborate with the health care team to design educational activities to meet the client s needs, to deliver the activities in a method that facilitates the learning needed, and to evaluate the process in an integral, ongoing, and systematic manner. Standard 11. Teamwork and Collaboration Social workers shall participate in care teams, and collaborate with other professionals, volunteers, and groups in and outside of their practice setting to enhance all aspects of the client and family system s care. Interpretation Social workers participate in multiple care teams, which are typically interdisciplinary. These teams often provide comprehensive care and information in a client s home, in outpatient or inpatient health, and mental health care settings. 25